Heart, Lung and Circulation最新文献

Background & aim: During the COVID-19 pandemic, cardiac rehabilitation programs (CRPs) rapidly transitioned to virtual, mostly one-to-one, care. Four years later, the lasting effects on contemporary program delivery are unknown. Therefore, this study aimed to examine the evolution of CRPs pre-COVID-19 to present (February-August 2024) in Canada.

Methods: A questionnaire was disseminated to Canadian CRP managers.

Results: Of 260 CRPs, 108 representatives of 150 CRPs (57.7%) responded. Since pre-COVID-19, there has been a reduction in proportion of CRPs offering a traditional in-person program model from 92.8% to 67.6% (p<0.001), an increase offering hybrid models (i.e., in-person with virtual components) from 12.0% to 43.7% (p<0.001), and an increase in virtual models from 24.6% to 50% (p<0.001). Pre-COVID-19, 71.5% of programs relied on one delivery model, declining to 51.1% post-COVID-19. CRPs offering 2-3 models rose from 28.5% to 48.9% (p<0.04). These models will continue in >89% of CRPs for ≥1 to 2 years. Program model allocation was based mainly on patient preference (41%) or patient/clinician collaborative discussions (35%), with 73.9% of these programs recommending in-person programming to higher-risk patients. There was an increase in CRPs that were under capacity pre-COVID-19 to present (6.3%-40.5%; p<0.001), yet the mean number of patients enrolled/month increased (+5.8%; 77±91 to 81.5±98; p<0.001). Exercise delivery is mostly group-based (>61%). Of all CRPs, >84% perceived that patients were at least somewhat satisfied with all model components, except fully virtual telephone (57.8%), unless the telephone was within hybrid models (72.2%). Resource and education barrier scores were lower for virtual and hybrid than for in-person programming (p<0.001). Patients with language/communication barriers presented the greatest challenge to exercise program delivery, with <54% of programs offering spoken language translation services for the in-person component.

Conclusions: The pandemic accelerated a shift towards diversified program models. Virtual, hybrid, and group-based models may be driving increased accessibility and reduced resource barriers, ultimately expanding patient reach. Further resource allocation is needed for language translation services to better serve diverse populations and accommodate in-person programming for people at higher medical risk and those with mobility deficits. A more widespread triaging process for tailored model allocation should be implemented by all CRPs. Leveraging technology to provide confidence that virtual-based programs are suitable for higher-risk and vulnerable populations, improving connectedness/peer support, and removing barriers for using technology for those who lack experience and/or have cognitive impairment are important initiatives.

Background: The long-term mortality of patients undergoing linear ventriculoplasty (LVP) for ischaemic left ventricular aneurysm (LVA) varies. This study aimed to develop a risk prediction model for mortality after LVP.

Method: A total of 741 patients with an ischaemic anterior-wall LVA who underwent LVP between January 1999 and March 2021 at Fuwai Hospital were retrospectively enrolled, and 22 clinical features were assessed. The entire cohort was randomly grouped into training and validation cohorts in a ratio of 8:2. Backward stepwise elimination approach and the least absolute shrinkage and selection operator regression were used for feature selection. A nomogram was developed based on a multivariable Cox regression model. The performance of the model was evaluated using discrimination and calibration. Decision curve analysis was performed to test the clinical usefulness.

Results: The mean age was 58.6 (standard deviation 9.6) years, and 15.8% of the patients were female. The mean ejection fraction was 42.8% (8.5%). Coronary artery bypass grafting was performed in 93.4% of the patients. During a median follow-up of 60 months, 105 patients died. Eight features were selected and included in the multivariable Cox regression-based nomogram. The model achieved good calibration and discriminative ability as indicated by the concordance index (training 0.71; validation 0.77). Decision curve analysis showed the model had good clinical usefulness.

Conclusions: In this study, a nomogram with relatively good performance was developed to predict individualised long-term mortality after LVP in patients with an ischaemic anterior-wall LVA. However, external validation is needed.

Background: The Australian Cardiovascular (CVD) Disease Risk Calculator is used to estimate the individual risk of developing cardiovascular disease in the next 5 years. A new version was recently published (July 2023), with the aim of improving on the predictive performance of its predecessor (released in 2012). We present the findings of an external validation study comparing the predictive performance of the 2023 and 2012 Australian CVD risk calculators using data prospectively collected in the Hunter Community Study (HCS; NSW Australia), a longitudinal community-based cohort of people aged 55-85 years.

Methods: We compared the risk predicted by the two calculators to the observed 5-year events in the HCS, in terms of discrimination (using area under the receiver operator characteristic curve, AUROC), calibration (using observed vs expected, O/E, ratio), sensitivity, and specificity.

Results: Discrimination was very similar for the 2023 and 2012 calculators, with AUROC measured to be 0.71 95% confidence interval (CI; 0.66, 0.75) and 0.71 95% CI (0.67, 0.75), respectively. With the updated calculator, sensitivity was better in males, while specificity was better in females; there were also modest improvements in positive likelihood ratios for both males and females. The 2023 calculator was found to overpredict risk for males (O/E ratio 0.57, p<0.001), but was better calibrated for females (O/E ratio 1.02, p=0.46).

Conclusions: We conclude that the 2023 calculator provides some improvements in the prediction of CVD, specifically the positive likelihood ratios. However, there are also benefits in observing the old 2012 calculator for some purposes and specific population groups. We find that there is a need for a larger, nationwide cohort to allow further external validation of the 2023 Australian CVD Risk Calculator.

Following guideline-directed medical therapy (GDMT) is crucial for managing acute heart failure (AHF). Australia has poor adherence to GDMT with only a small proportion of eligible patients receiving optimal HF therapy. Therefore, there is a real need for unified recommendations to optimise GDMT for patients hospitalised with AHF in Australia. Using a modified DELPHI method, an expert panel of nine Australian clinicians with expertise in HF management convened to develop consensus statements aimed at guiding healthcare professionals in Australia on optimising GDMT. This document outlines a strategy for ensuring patients are started on GDMT while they are in hospital and that GDMT is optimised to maximum tolerated doses rapidly after discharge. This is especially critical because rapid optimisation of heart failure (HF) therapies and close follow-up in the early period after HF hospitalisation has been found to decrease all-cause mortality and reduce the risk of HF readmission. These consensus statements provide a practical framework to help Australian healthcare professionals in optimising GDMT for their patients. This framework is designed to enhance the current AHF guidelines. The consensus statements support the ongoing priority of optimising GDMT for AHF management aiming to ensure that eligible patients receive the optimal therapy for their clinical presentation.

Background: Historically, high-risk percutaneous coronary intervention (PCI) procedures such as rotational atherectomy (RA) required on-site surgical backup. However, advancements in PCI techniques, coupled with the geographic realities of Australia's dispersed population, warrant a reassessment of RA in the context of contemporary clinical practice.

Aim: We aimed to establish the safety and outcomes after RA at non-surgical centres.

Method: Consecutive RA PCI cases from September 2012 to February 2024 at seven Australian hospitals without on-site cardiac surgery were analysed. Primary outcomes were referrals for emergency cardiac surgery (bailout) and 30-day mortality.

Results: A total of 943 patients (1,010 lesions) were included, with a mean age of 74.4±9.6 years. A total of 72.6% were male and the average body mass index was 28.7±7.1 kg/m². Common comorbidities included diabetes (35.1%), a history of smoking (48.7%), and acute coronary syndrome or emergency presentation (32.9%). Off-site surgical bailout was necessary for four patients (0.4%) (temporary pacing wire-related right ventricular perforation with tamponade [n=2]; burr entrapment not retrievable percutaneously [n=2]). Major coronary perforations occurred in 0.8% (n=8; Ellis III). Minor perforations occurred in 2.3% (n=22). Tamponade occurred in eight (0.8%) patients. Burr entrapment occurred in six (0.6%) patients. A total of 32 patients (3.4%) died within 30 days of the procedure; 13 cases (1.4%) were PCI-related, but only eight of these (0.8%) were directly attributable to RA (significant ischaemia, e.g., no/slow reflow [n=4]; perforation with tamponade unable to be temporised percutaneously [n=2]; burr entrapment [n=1]; extensive coronary dissection [n=1]). Female sex and acute coronary syndrome presentation were predictors of poorer outcome.

Conclusions: RA can be safely conducted without on-site surgical backup, including in regional Australian areas. In geographically dispersed populations, regional access to RA-assisted PCI is critical. Immediate percutaneous management remains the mainstay of management of rare but potentially severe complications such as tamponade, perforations, and burr entrapment.

Aim: Increasing evidence supports the use of fractional flow reserve (FFR) to accurately identify which coronary artery lesions are appropriate for intervention. We aim to describe the use of FFR-guided percutaneous coronary intervention (PCI) in a large Australian PCI registry.

Method: We assessed data from consecutive patients in the Victorian Cardiac Outcomes Registry from 2014 to 2020 who presented with stable coronary artery disease or non-ST-elevation acute coronary syndrome and underwent FFR-guided PCI in a single procedure. They were compared with a cohort who underwent standard angiographically guided PCI over the same period.

Results: A total of 59,401 patients were included in the study with 2,455 (4.1%) undergoing FFR-guided PCI. Patients who underwent FFR-guided PCI less often presented with a non-ST-elevation acute coronary syndrome (22% vs 39%, p<0.001), were less probable to have their procedure out of hours (4.8% vs 10.6%, p<0.001), and more probable to have radial access (70% vs 59%, p<0.001). The use of FFR increased over the study period (2.8% of all cases in 2014 vs 4.7% in 2020, p<0.001). FFR-guided PCI was more often performed on the left anterior descending artery (65% of all cases vs 42%, p<0.001). The 30-day mortality was less in the FFR-guided group (0.2% vs 0.6%, p=0.005) but the overall mortality was very low.

Conclusions: This observational study demonstrates that the frequency of use of FFR to guide PCI was low in the Australian context; however, use is increasing. Patients in the FFR-guided group had lower 30-day mortality, although the overall rates of mortality in the study were very low.

Background: Atrial fibrillation (AF) significantly contributes to rising healthcare costs in Australia, with inpatient care accounting for most expenses. Recent literature has explored the use of a "wait-and-see" approach to managing patients presenting to emergency departments with primary AF given the high rate of spontaneous cardioversion (SCV), thereby avoiding invasive cardioversion and costly hospital admission. Limited adoption of this model of care may stem from challenges in identifying patients who truly need admission. To address this, predictive models for SCV are being explored. Our study aims to determine the accuracy threshold at which such models achieve cost savings by preventing unnecessary AF admissions.

Method: A decision-analytic model was used alongside Monte Carlo simulations to estimate the variability in cost per patient with changes in prediction model accuracy and expected rates of SCV. Estimated costs were derived from a sample of patients presenting to Flinders Medical Centre or Noarlunga Hospital, South Australia in 2022-2023 with primary AF.

Results: There were 669 admissions at Flinders Medical Centre or Noarlunga Hospital for primary AF in 2022-2023. SCV occurred in 240 (35.9%) cases, representing potentially avoidable admissions. The base case cost per admission was AUD$5,793.94, further increasing to $7,009.42 if interhospital transfer was required. The point at which cost benefit would be observed in our patient cohort was between 60% and 70% accuracy. There was an incremental reduction in cost in relation to increasing prediction model accuracy or population SCV rate.

Conclusions: Predicting SCV with an accuracy of 60%-70% in patients presenting with primary AF results in cost savings and reduced hospital bed utilisation through avoiding unnecessary admissions.

Background: Patients with end-stage heart failure experience a significant symptom burden that is often poorly controlled. Although palliative care can improve symptom management and reduce hospital admissions, many patients still die in acute care settings. The unpredictable course of end-stage heart failure complicates the identification of patients who would benefit from early palliative care referral. To address this challenge, an integrated cardiac supportive care service was developed to engage these patients early, optimise symptom control, and ensure timely access to palliative care.

Aim: The aim of this study is to document the symptom burden, using Patient-Reported Outcome Measures, for patients with end-stage heart failure on admission to the cardiac supportive care service.

Method: A prospective observational study was undertaken in a tertiary hospital service in Sydney, Australia between January 2020 and July 2022. Patients were included if they had a recent admission for heart failure or had heart failure with breathlessness or chest pain at rest or on minimal effort. The cardiac supportive care service, consisting of initial home visits and follow-up reviews conducted by a palliative care physician and cardiac nurse practitioner, collected information using the Dyspnoea-12 (D-12) Questionnaire and the Integrated Palliative Care Outcome Scale (IPOS). Symptom scores from these tools were analysed in relation to patient mortality, with Kaplan-Meier survival curves and Cox regression used to assess the association between symptom burden and time to death.

Results: A total of 114 patients were included in this study. Both the IPOS and D-12 scores indicated a substantial and clinically relevant symptom burden for this cohort of patients. High mean scores on the IPOS were observed for weakness (2.6, standard deviation [SD] 1.2), shortness of breath (2.6, SD 1.2), and sore/dry mouth (2.5, SD 1.3). Sore/dry mouth was the most frequent severe or overwhelming symptom (59%). The D-12 showed that descriptors of breathlessness most commonly rated as severe were "My breathing is exhausting" (40%), "My breathing is distressing" (39%), and "I feel short of breath" (38%). Patients with an IPOS score in the highest quartile had an elevated mortality risk. The survival of patients in this cohort was 17.1 months.

Conclusions: Patients with end-stage heart failure experience a substantial and frequently severe symptom burden, including breathlessness, dry mouth, and weakness. This study demonstrates the significant unmet need in this patient population and highlights the opportunity for integrated and proactive palliative care, delivered through a cardiac supportive care service. This model of care can optimise symptom management, facilitate advance care planning, and ensure timely referral to palliative care.